Posted by Larry Hoover on January 1, 2006, at 13:47:23
In reply to Endocrinology consult, posted by Tabitha on December 31, 2005, at 13:36:09
> I just had another awful doctor visit. So I've been taking 50 mcg cytomel for about a year now. I'm not doing this under a doctor's orders, and I don't know what my blood levels were before starting. I did have an Rx for 25 mcg from my old pdoc at one point though, and started off with old medicine from that Rx.
Okay, no baseline data. And, what made you consider this line of treatment?
> It's really helped me a lot, with fewer side effects than any psych med. This year has just been a huge improvement in my functioning. The most remarkable change is in my energy level and my sleep patterns. I'd struggled with low daytime energy and insomnia at night leading to a night-owl pattern for most of my life. Since I've been on this med, I don't even think about 'having energy' in the daytime anymore. It's just there. And I go to sleep at a normal hour in 20 minutes or so, and sleep well. It's just miraculous to me.
In another thread, you're claiming middle age? Doesn't sound like middle age, to me.
You've really got my attention, now.
> Also my thinking feels sharp again. I do brain-work in my profession so this is really important to me. So many psych meds make me feel stupider.
>
> And my hair quit falling out and the texture improved. My hair had been falling out for 5-6 years and had gotten really coarse and awful.I think you've discovered the Fountain of Youth. I am now rapt.
> I don't have any hyperthyroid symptoms except a tiny bit of increased irritability. But I asked my primary care doc for bloodwork (this was 6 months ago) and my free T3 level was way higher than normal, so she told me to just quit taking the cytomel, I don't need it. Well I insisted on an endocrinology consult, and it took 6 months to get in. He told me a slight variation on the same, it's dangerous, creates risk for heart arrythmia and osteoporosis, and told me to taper down to 12.5 mcg then come back in 3 months. Three months!
>
> And since I didn't have bloodwork beforehand, I don't know that I'm not hypothyroid to begin with, and they can't possibly tell that based on my current blood levels. So it doesn't make sense to me to cut the dose in 1/4 then not be checked for 3 months.Free T3 is only one measure to consider. Were other analyses made? TSH? Total T3?
I can give you the textbook reason for his response to you. Most of your T3 is circulating in your blood attached to carrier proteins. Generally, a very small amount is circulating free of this protein. Think sponges. The protein soaks up the T3, and has a varying degree of saturation. The closer this protein comes to saturation, the greater the percentage (and thus, absolute amount) of free T3. So, by inference, a high free T3 level suggests a long-term oversupply of this hormone. You're saturated. The sponges (carrier proteins) can't hold any more.
The physiological purpose of these carrier proteins is to provide a constant and stable supply of T3. They're in what's called a dynamic equilbrium with free T3. A wet sponge will dampen a dry object, but soak up free water from a wet one. Free T3 is constantly being soaked up by these carrier proteins, but it is also constantly being released.A good example of a dynamic equilibrium is people in an airport. There might be 5,000 people coming to the airport every hour. And 5,000 people leaving. Inside the terminal, there's a stable 15,000. The number stays stable (equilibrium), but the individual people constituting the assembled mass are constantly changing (dynamic).
What your doctor wants you to do is to decrease the number of people entering your airport terminal. In so many words. With constant rate of exit, the airport population will decrease, dynamically, over time.
He's assuming your thyroid transport proteins are so saturated, that it will take three months at the decreased intake level to show a significant change in free T3, and restabilization at a new equilibrium value. He's also assuming that you need *some* supplemental T3. He didn't say to stop it, entirely.
> I asked him what about all the symptoms that were improved, he said I need another specialist for that, he only does hormones.
Huh? He just does numbers? He doesn't look at response?
> I asked what kind of specialist would that be, he said a psychiatrist. I said how could my hair falling out be a psychiatric symptom? He said he didn't know, I should ask my primary care about it.
Oh, boy! I am astounded.
> Well I've asked every primary care doc about it, they've not referred me to any specialist. I asked my ob/gyn if it could be hormonal, she said it's most likely thyroid.
Wow. That's quite a runaround you're getting. Is this what happens with managed care?
> And I told him I'd been Rx'd 25 mcg from my pdoc, he said that psychiatry and endocrinology disagree on using T3. Yet he's telling me to go to a psychiatrist. It's sort of comical.
I'm glad you have that sense of detachment. I could imagine you'd not see the humour in it.
> So I looked up all the old research I'd looked up before starting, and it looks to me like using 25-50 mcg for bipolar and depression isn't that unusual. And I see stuff saying the risk of heart arrythmia and osteoporosis is controversial, and some says it only applies if you're hyperthyroid for long term, and since I don't have symptoms of hyperthyroid, despite the unusual blood levels, I don't really understand whether I'm at risk or not.
You've done your homework. You're correct. Almost. Long-term hyperthyroid, and male. I don't think you meet that latter criterion.
Statistically, you're not at risk. But you're an individual. Bone density and heart rhythm disturbance are manageable. If needed.
> He took my pulse, seemed surprised that it's a perfectly normal 72. So he said the only reason I'm 'tolerating' this med so well is that I'm fairly strong.
My goodness. He wants to ignore all the evidence that you're well.
> Oh, and I asked couldn't I be monitored for osteoporosis and heart arrythmia, but he said it was still too dangerous. And he thinks I 'probably' haven't lost bone since it's only been a year. Well I've asked my doctor for bone density scans, which has been recommended to me anyway as a normal thing for an over-40 woman to get a baseline, and my doctor says no I don't need it since I don't have risk factors.
That's managed health care, isn't it. No risk factor, no scan. I get it.
> Yet he's telling me it's a risk factor, and not ordering a test.
You have every right to feel under-treated. This borders on malpractise, IMHO.
> I guess I expected that he'd check my blood levels and switch me to a T4 or a T4/T3 combo, since I know endos don't use T3 alone. But he's just telling me to drop to 1/4 dose and go away for 3 months based on my current blood level.
He's actually giving hypothyroid some credence, inferentially, even though he won't say that to you. His behaviour is not absolutely dismissive.
> I had also read that if you're on a T3 drug, you're not supposed to take the med on the day of the bloodwork, so I didn't really think it was that valid of a reading. I had taken it probably 2-3 hours prior to the test.Excuse me? You could not have purposefully ruined that blood test any more than you did by happenstance. The test results are worthless.
The thyroid hormone enters your bloodstream unbound, i.e. free. The results of the bloodwork simply show that you just took some oral T3.
If you go to the Cytomel drug monograph, you'll see that uptake (entrance into blood) is 95% at 4 hours. You'll also see that the biological half-life is 2 1/2 days. So, to have an undisturbed picture of background thyroid function, 24 hours of abstinence might not be enough.
http://www.rxlist.com/cgi/generic3/liothyronine_cp.htm> The most bothersome thing is neither doctor is willing to consider that I might actually be hypothyroid without this medication.
You don't have evidence that they are accepting. They're ignoring your clinical response. The numbers mean nothing, if not interpreted in the context of clinical response.
> Now I'm confused about what to do. I could just ignore them and keep doing my own thing. I could go to a private lab and get my own bloodwork. I could go back to the pdoc who Rxd the 25 mcg and ask for advice and monitoring. I could go to a different GP I know of who's supposed to be progressive about thyroid and hormone stuff. I could call this one back and argue some more, and ask to come back earlier than 3 months.You need some new bloodwork. What you had six months ago, or whenever, is meaningless, because you used Cytomel just prior to the draw.
Either one of the pdoc or the hormone-friendly GP sound like good ideas. I'd lean towards the GP.
> The only thing I don't want to do is taper down to 12.5 mcg and stay there for 3 months without any further monitoring.I agree with you. Your analysis of the situation is admirable. In my opinion, you are assessing this drug in the entire context of your life. Each doctor is not doing that. They are isolating their interpretation to very limited context, and, they are all relying on bloodwork which is distorted by an uncontrolled variable. Meaningless numbers.
By the way, if you had TSH done, way back when, as part of that "flawed" bloodwork, if the number is measurable, your body is still making its own T3. In other words, the amount you're taking is not "too much".
> I just can't see how that makes sense at all. I'm pretty mad that I waited 6 months and got the 15 minutes of face time and that was the whole response.
Medical arrogance, IMHO. Some guy, with a cushy and lucrative 9-5 gig, not connecting with his patient.
> This med has really been life-changing for me. And I guess I'm just used to the way pdocs do things, where you weigh risks and benefits, and experiment and go with what works, and then try to offset the risks. All meds have risks, right?
Right. And you've accounted for those.
> It's just not making sense, yet I'm pretty upset by the visit. I don't like going against doctor's orders.
I understand that. People make mistakes. Doctors too.
> I really am worried about giving myself osteoporosis.
You're too smart to let that happen. It happens because of neglect. You'll be fine.
> And I don't like knowing that this is on my health records.
It won't matter, if you're right.
Lar
poster:Larry Hoover
thread:593741
URL: http://www.dr-bob.org/babble/health/20051214/msgs/593968.html